Carinal Resection and Reconstruction

At the lower end of the trachea, the special problems (anatomic, technical, and anesthesiologic) of cari-nal reconstruction loomed. Lesions, most often neoplastic, were centered in the carina, extended to the carina from low in the trachea, or to the carina from main bronchi or lungs. Experimentally, Grindlay and colleagues resected right lung and carina in dogs in 1949, with end-to-end anastomosis of trachea to left main bronchus.103 Ferguson and colleagues also performed right and left pneumonectomies in dogs in 1950, with resection of carina and end-to-end anastomosis.43 In 1951, Juvenelle and Citret, working at the University of Buffalo, showed experimentally the feasibility of lateral implantation of bronchus into trachea, without loss of blood supply and without interference in ventilation.104 They further described experiments in which they resected the carina with a three to four ring segment of trachea, and then anastomosed the trachea to the right or left main bronchus and implanted the other main bronchus into the side of the trachea. They found it necessary to free the trachea to reduce otherwise excessive tension. Additionally, they remarked that freeing the trachea permitted anastomosis of the trachea directly to right and left main bronchi without excessive tension, after short segment resection.105 Meyer and colleagues experimentally implanted the right upper lobe and right main bronchus into the trachea in 1951.106 Ehrlich and colleagues, in 1952, transposed a right main bronchus to the lateral tracheal wall, and later resected the left lung and carina in dogs.107 Kiriluk and Merendino, in 1953, described a variety of experimental tracheal, bronchial, and carinal reconstructions, including reapproximation of both main bronchi to the carina and tracheobronchial anastomosis after carinal pneumonectomy.45 Nicks similarly reconstructed the carina after resection in pigs in 1956, but under hypothermia.62 In 1958, Bjork and Rodriguez described experiments in reconstruction by direct anastomosis after resection of the carina and twelve tracheal rings in dogs.108 The right main bronchus was sutured end-to-end to the trachea and the left main bronchus end-to-side to the intermediate bronchus. This followed the similarly successful clinical procedure by Barclay and colleagues, described below.109 The same anastomoses after carinal resection were performed in dogs in 1969 in confirmatory studies.110

Clinically, Abbott repaired large oval defects created by right pneumonectomy and right carinal lateral excision for bronchogenic carcinoma in 5 patients in 1950, by transverse closure.111 Two of the patients died. Other patching techniques were used to repair such lateral defects, including dermal grafts, synthetic materials, and patches or flaps of retained bronchial wall.112,113 These complex and frequently unsuccessful patch techniques are reviewed in Chapter 45, "Tracheal Replacement."

In 1951, Mathey locally resected a "cylindroma" of the back wall of the trachea at the carina, including posterior walls of both proximal and main bronchi.114 Repair was effected by longitudinal suture of the medial bronchial margins and transverse suture of the remaining defect. In these years, surgeons struggled with the problem of tracheobronchial anastomosis at the carina. In 1954, Crafoord and colleagues reported anastomosis of the bronchus intermedius to the trachea at the site of main bronchial origin, after upper lobectomy and bronchial excision.115 The next year, Bjork obtained access to the carina from the left chest, mobilizing the aorta after division of four pairs of intercostal arteries, in order to successfully resect the left main bronchus and anastomose its lobar bifurcation to the prior origin of the bronchus at the trachea.116 In 1959, he presented follow-up of 16 patients who had undergone bronchotracheal anastomosis, with four stenoses.117 Abbey-Smith and Nigan described a similar left-sided approach in 1979, for amputation of the left main bronchus at the carina, for pneumonectomy in a case of proximal lung tumor.118

Barclay and colleagues, in 1957, resected about 5 cm of trachea and carina to remove a recurrent adenoid cystic carcinoma.109 Division of the pulmonary ligament allowed anastomosis of the trachea to the right main bronchus. The left main bronchus was anastomosed end-to-side to the bronchus intermedius. Intermittent ventilation sufficed for the second anastomosis. A second patient was handled identically. Both patients recovered. The authors reported in the same paper that dissection in fresh cadavers prior to operation permitted resection of 6 cm of trachea, using this technique. They also proposed, where carinal resection was not required, to close the left main bronchial stump. Eschapasse and colleagues used this technique in 1961.119 Archer and colleagues similarly excised a granular cell myoblastoma at the carina in 1963.120 The procedure was a major step in carinal surgery. Grillo and colleagues described resection of the carina and trachea for a length of 4 cm to remove adenoid cystic carcinoma, in 1963.121 The right hilum was mobilized and the trachea anastomosed to the right main bronchus. The left main bronchus reached the trachea easily enough to be anastomosed there end-to-side. The patient did well. Cross-field intubation and ventilation were used. Temporary occlusion of the pulmonary artery to the nonventilated lung eliminated shunting, but later rarely proved to be necessary. In 1966, Mathey and colleagues reported results in 7 patients, who underwent carinal excision with or without bronchial resection, using thoracotomy.40 They believed, however, that sternotomy might be preferable. Three patients had pneumonectomy, and 2 had partial lung resection. The following anastomoses were done: trachea to main bronchus; side-to-side left main and intermediate bronchus and both end-to-end to trachea; 2 patients had dermal graft patches. There were 2 postoperative deaths. Eschapasse and colleagues, in 1967, cited 3 patients who had circumferential resection of the entire carina with primary reconstruction.122 Anastomoses were of right main bronchus to trachea with left main end-to-side to bronchus intermedius in 2; left main to trachea with intermediate bronchus to left main. One patient died postoperatively. Eschapasse favored right thoracotomy, cross-table ventilation, avoidance of prostheses, and primary reconstruction (Figure 3). Anesthesia for carinal resection, which had initially seemed formidable, was managed easily enough in patients by cross-table ventilation of the trachea and bronchi as the procedure progressed, so that ventilation was not interrupted or uncontrolled at any point.

Nonetheless, the anesthetic challenge of carinal resection suggested the use of extracorporeal circulation to some. Nissen removed a "malignant adenoma" in this way.123 Under bypass, Woods and colleagues excised recurrent "cylindroma" from the carina with very limited margin.124 Reconstruction was by suture and a patch of skin supported by wire mesh. Adkins and Izawa performed lateral resection of the carinal wall for cylindroma, patching the defect with Marlex and mediastinal tissues.125 As might be expected, granulation tissue formed at the patch site. The considerable potential for hemorrhage due to the need for heparinization during bypass was not encountered in these technically limited cases.

Experience with carinal resection and reconstruction grew slowly. In 1974, Eschapasse collected 19 cases from several French teams, Perelman and Koroleva recorded 29 carinal resections with reconstruction in 1980, and Grillo had performed 36 carinal reconstructions by 19 82.99,126,127 Twenty-three of Grillo's group were primary tracheal neoplasms, 5 were bronchogenic carcinomas, and 8 were inflammatory lesions. Eleven were reconstructed without loss of lung tissue. On the basis of this experience, Grillo presented a comprehensive schema for carinal reconstruction.99 For short resections, carinal restoration was by side-to-side main bronchial anastomosis, which was then joined end-to-end to the trachea; for longer lesions, the trachea was placed end-to-end to the left main bronchus (if the gap was less than 4 cm) and the right main bronchus end-to-side to the trachea; for still more extensive tracheocarinal removal, the "Barclay" anastomosis of the right main bronchus to the trachea and the left main bronchus end-to-side to the intermediate bronchus was used. Other special problems were also presented, including the problem of lesions involving a long length of trachea and also of the left main bronchus. Recent exploration of problems with carinal reconstruction has updated this experience in 143 resections.128

Approach for carinal resection via right thoracotomy has been preferred by most surgeons.99,121,126,129,130 Left thoracotomy with subaortic dissection was employed for specific lesions, principally those involving the left main bronchus and the carina, but little of the tracheal length.40,99,126,131,132 Left thoracotomy with retroaortic dissection was also explored early, but failed to gain acceptance.116,118 Median sternotomy for carinal access was described in 1907 by Goeltz for foreign body removal, in 1960 by Padhi and Lynn for bronchopleural fistula, in 1961 by Abruzzini for treatment of postpneumonectomy tuberculous fistulae, and was reintroduced with anterior and posterior peri-cardial opening by Perelman (Figure 4).i30,i33-i35 Pearson and colleagues favored this approach for cari-

figure 3 Henry Eschapasse, MD, Chief of Thoracic and Cardiovascular Service Emeritus, Regional Hospital Center of Toulouse, and Professor Emeritus, University of Toulouse. In the decades post World War II, there was great interest and activity in tracheal surgery and pathology in France. Dr. Eschapasse was a leader in this field, and especially interested in the study of primary tracheal neoplasms and carinal reconstruction. Toulouse became a center for tracheal surgery.

nal resection.136 Maeda and colleagues added left anterior thoracotomy to sternotomy to improve access.132 Grillo employed bilateral thoracotomy ("clamshell" incision) for free access to the carina and to both thoraces for treatment of complex lesions, especially those involving the left main bronchus, carina, and a long extent of the lower trachea.99

figure 4 Mikhail I. Perelman, MD, Consulting Surgeon, National Research Center of Surgery, Moscow, and Professor of Surgery and Physiopneumonology, Moscow Medical Institute. Professor Perelman had an early interest in airway surgery, acquired a large clinical experience, and published the first comprehensive books in the field. Tracheal tumors were a special interest of his.

figure 4 Mikhail I. Perelman, MD, Consulting Surgeon, National Research Center of Surgery, Moscow, and Professor of Surgery and Physiopneumonology, Moscow Medical Institute. Professor Perelman had an early interest in airway surgery, acquired a large clinical experience, and published the first comprehensive books in the field. Tracheal tumors were a special interest of his.

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